APPLICATION FOR
COMMERCIAL GENERAL LIABILITY
Fire Protection Engineers

(This is an application for annual “per occurrence” coverage)

A) Please answer all questions in ink, leaving no blank spaces. PLEASE PRINT OR TYPE
B) The application must be signed and dated.
C) When answering questions, please use a separate sheet of paper if space provided is insufficient.
APPLICANT INFORMATION:
1c) Applicant is:
1e) Any operations sold, acquired, or discontinued in the last five years?
1f) Number of employees:
1g) Financial Information:
 Gross IncomeStaff PayrollSubcontractor Payroll*
Past Twelve Months:
Estimate of Next Twelve Months:
(*Subcontractors are not covered unless added by endorsement)

4a) Please provide a description of your activities below by showing the percentage of income derived from each and a brief description of each.  Use a separate sheet of paper if necessary.  (Attach any brochures or fliers, if available).

4b) Do you perform any activities off-shore or overseas?
PREVIOUS INSURANCE:

5) Please provide prior carrier information for the last three (3) years:

5a) Commercial General Liability                                                                                       LIMITS:
 Expiration DateCarrierPolicy NumberPolicy TypeGeneral AggregateProducts AggregatePer OccurrenceTotal Premium
.
.
.
5b) Professional Liability
 Expiration DateCarrierPolicy NumberLimitsDeductibleTotal Premium
.
.
.
5c) Has any similar insurance for the Applicant or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant ever been cancelled or declined or refused renewal?
LOSS HISTORY:
6a) Have any claims or suits been made during the past ten years against the Applicant, or any person now a principal or owner of the Applicant, or any predecessor entity or any prior entity owned or previously owned by a current principal or owner of the Applicant?
6b) Upon inquiry of all personnel, is the Applicant, or any employee, manager or owner of the Applicant, aware of any circumstance, incident or situation, which may result in a claim?
6c) Have all claims and circumstances requiring a response in questions 6a) and 6b) already been reported to and accepted by a current or past Insurer?
ADDITIONAL INSUREDS:

GENERAL POLICY INFORMATION:

8) Policy Period Requested:
calendar
calendar
9) Policy Limits Requested (Per Occurrence/General Aggregate):

NOTE: Professional Liability must be maintained through our office in order to bind the General Liability. If you wish to bind the $2,000,000/$2,000,000 limit on the General Liability, Underwriters will require the Professional Liability must be at $1,000,000/$2,000,000 limits.

I hereby declare the above statements and particulars are true, and that I have not suppressed or misstated any material facts.  At the present time, I have no reason to anticipate any claim being brought against me, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between myself and the Underwriters and shall be deemed a part thereof.

This Proposal Form duly completed, together with any supplementary information, must be signed in ink by the Applicant.
Completion of this Proposal Form does not obligate the Applicant or the Insurer to complete this insurance.
COMPLETE EQUITY MARKETS, INC.
(In California dba Complete Equity Markets
Insurance Agency, Inc. CASL#0D44077)
1190 Flex Court
Lake Zurich, IL 60047
www.cemins.com
Toll Free: (800) 323-6234
In Illinois: (847) 541-0900
Fax:(847) 541-0444

LII 301 A (08/09)                                                                          THIS DOCUMENT MUST NOT BE ALTERED OR DUPLICATED